Instt. (for office use) Please read instructions in the Prospectus carefully before you start to fill up the application form in your hand-writing.
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1 APPLICATION FORM B.Sc. (MT) Radiography Course Affix one recent UNIVERSITY COLLEGE OF MEDICAL SCIENCES Photograph here duly G.T.B. HOSPITAL, DELHI attested on the front (SESSION : ) side by a Gazetted Officer/ Principal of a Recognized College/ Form No. Instt. (for office use) Please read instructions in the Prospectus carefully before you start to fill up the application form in your hand-writing. 1. Name of the Candidate (In BLOCK letter) : 2. Date of Birth : Day Month Year 3. Age as on (Must have completed 17 years.) 4. Gender (Tick) : Male Female Others 5. Marital Status : Married Unmarried 6. Nationality : 7. address. 8. Mobile No. of the Candidate.. Land line No.. 9. Do you belong to General Category? Yes No 10. Do you belong to Scheduled Caste? Yes No (if yes, attach copy) 11. Do you belong to Scheduled Tribe? Yes No (if yes, attach copy) 12. Do you belong to OBC? Yes No (if yes, attach copy) 13. Do you belong to Person with disability (PWD)? Yes No (if yes, attach copy) 14. In-Service Candidate Yes No (if yes, attach proof) Aggregate percentage of marks obtained in the qualifying exam. : % (Result declared/ yet to be declared) 15. (a) Father s or Guardian s Name (In Block Letters) :. Occupation.. address.. Mobile No... (b) Mother s Name (In Block Letters):.. Occupation.... address.. Mobile No... (c) Relationship (in case of Guardian) :.. (d) (e) Annual Income (Rs.):.. His/her permanent address & Telephone No./Mobile No. (if any ) : Details of Examinations Passed or appearing for: Examination passed (or appearing) Matriculation SSE/ Higher Sec./Pre-University 10+2 system or equivalent, specify Any other exam. such as 10+2 in X-ray, or Certificate/2 yr. Diploma in X-ray Tech. Name of the Sch./ Coll. & board Year & month of passing or appearing Roll No. at the exam Marks Obtained In The Exam. Phy. Chem.Bio.Eng (PCBE) Div. if any with total %age of marks Remarks, If any 1
2 17. University Enrolment No. :.. (If issued earlier by University of Delhi, in case the candidate has earlier passed any course from the University). N.B. (i) In case of 10+2 system, the, Board/University and Roll No. must be mentioned. (ii) If there is a break in the studies, if should be clearly mentioned, giving reason (s) for the interruption of the studies in the remarks column or the space below. (iii) Attach attested true copy of the mark sheet. 18. Address for correspondence (in full) including PIN code to which reply regarding this application may be sent (with Telephone No.) if any. DECLARATION BY THE CANDIDATE I hereby declare that the application form has been filled in my own handwriting and that the information given by me in the above application form is correct. I further declare that I have read the rules as given in the Prospectus. I shall abide by the rules and regulations of the College and University of Delhi. Place Date Signature of the applicant Name: DECLARATION BY THE PARENT OF THE CANDIDATE OR THE GUARDIAN OF THE CANDIDATE IN CASE NEITHER OF THE PARENTS IS ALIVE I hereby solemnly affirm and declare that the information furnished by the candidate is correct and nothing has been concealed. In the event that any false information has been furnished or that there has been suppression of any factual information in the application form, or comes to notice of the Institute authorities at any time during the course, he/she would be liable to be terminated besides other action by the Institute as may be deemed fit. I further declare that I hold myself responsible for the timely payment of all dues, i.e. tuition fee, fines and other charges payable to the University College of Medical Sciences in respect of my son/ daughter/ ward during the period of his/ her studies at the College and thereafter until the accounts are cleared. Address : Signature of the Parent/ Guardian Name: Date : DECLARATION BY THE SCHEDULED CASTE/TRIBE/OBC/PWD APPLICANT ONLY I hereby declare that I belong to a Scheduled Caste/ Tribe/ OBC/ PWD category and that I desire admission to the Institution under the special category for such candidate and I enclose herewith a Certificate from the prescribed authority as proof of the same. Enclosures :
3 PROFORMA FOR CERTIFICATION FROM THE PRINCIPAL OF THE SCHOOL/COLLEGE LAST ATTENDED 1. Certified that Mr./Ms... S/o/D/o... has studied in (Name of the Course)... at (Name and Address of the School/College). from (mm/yy)....to (mm/yy). ( years). 2. Certified that Mr./Ms... has studied in this School/College a regular student. 3. He/ She has appeared/passed.. examination under 10+2 system in (mm/yy)... conducted by the... (Name of the Board/University). 4. He/ She bears a good moral character. 5. This College is recognized by. (Name of the Board/University). 6. Date of Birth as per the Secondary School Certificate: Date Signature of the Principal and seal of the School/ College. 3
4 ATTENDANCE SHEET Admission to B.Sc. (MT) Radiography Course Saturday, 18 th June, 2016 Entrance Exam. UNIVERSITY COLLEGE OF MEDICAL SCIENCES, DELHI (To be attached with the application form after affixing the photograph) Form No. Reg. No. 1. Name (in BLOCK letters) :.. 2. Father s Name :.. Affix one recent Photograph here duly attested on the front side by a Gazetted Officer/ Principal of a Recognized School/ College/ Institution. (Signature of the Candidate) Do not fill/or Sign below this line while submitting the application For use during examination (For office use only) Signature of the candidate at the time of examination Date Signature of the Invigilator (In case the candidate is absent Invigilator may please write ABSENT and put his signature. 4
5 Admit Card ENTRANCE EXAMINATION - B.Sc. (MT) RADIOGRAPHY COURSE Saturday, 18 th June, 2016 at A.M to Noon Form No. To be completed by the candidate Affix one recent Photograph here duly attested on the front Full signature of the candidate side by a Gazetted (Signature with office stamp of officer/ Principal of a the Gazetted officer attesting the Recognized College/ Entrance Test- Date signature of the candidate) Institution 18 th June, 2016, For office use only Centre ROLL NO. College Block, UCMS &.G.T.B. Hospital, Dilshad Garden Delhi-95. PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY. 1. You must present this admit card at Examination Centre for securing entry to the Examination Hall. 2. You must present yourself at the Examination Centre on 18 th June, 2016 before a.m. 3. You must read carefully the instructions printed overleaf. 4. In future correspondence, you must quote your Roll No. IN CASE, YOU ARE FOUND ELIGIBLE FOR ADMISSION, YOU HAVE TO FULFIL THE FOLLOWING CONDITIONS: (i) Submission of photographs. (ii) Submission of attested true copy of the Matriculation/Secondary School Exam. Certificate issue by the University/ board showing your date of birth. (iii) Submission of certificate of good conduct from Principal/Head of the Institution last attended. (iv) Submission of attested true copy/ photocopy of certificate from the prescribed authority stating that you belong to a Scheduled Caste/ Tribe/ OBC community. (In case, you belong to a Scheduled Caste/ Tribe/ OBC and you have applied for admission against the reserved quota. (v) Submission of documentary evidence of your having passed qualifying examination with the required percentage of marks and subjects latest by 11 th June, 2016 falling which your performance at the Entrance Examination shall not be considered. To be filled by the candidate Name: Father Name: Address: Tel.: State Pin Code Section Officer (Acad.) FOR OFFICE USE ONLY UNIVERSITY COLLEGE OF MEDICAL SCIENCES G.T.B. HOSPITAL, DELHI Form No. Received an application form from Mr./Ms... S/o/D/o for admission to B.Sc. (MT) Radiography Course Section Officer (Acad.) 5
6 INSTRUCTIONS FOR THE CANDIDATES Read the following instruction carefully. DO s 1. The candidate must bring the admit card (without the envelope) with him/her to secure admission to the Examination hall (failing to do so, shall render him/her liable to expulsion. This shall be checked and verified during the examination). 2. The candidate should bring his/her own fountain pen or black ball point pen for the examination. 3. The candidate must write his/her own Roll Number on the answer sheet in the space provided for it. 4. The candidate should sign the attendance sheet when directed to do so by the invigilator. 5. The candidate must observe silence in the Examination Hall (Any candidate found guilty of disorder or improper conduct shall be liable to expulsion from the Examination Hall). 6. The candidate is under the disciplinary control of the Superintendent of Examination and required to obey his/her instruction. The candidate who fails to observe these instructions shall be disqualified and debarred from appearing in this and in any subsequent examination (s) to be held by the Institution. 7. The candidate should leave the room only after handing over his/her Test Booklet and Answer Sheet to the Invigilator. DONT s 1. Do not bring any article other than specified in the instructions including the envelope in which admit card was mailed to you. 2. Do not copy from the paper of any candidate or permit his/her own papers to be copied or attempt to give or obtain irregular assistance of any kind. 3. No entry into the Examination Hall after beginning of entrance test. 4. Cannot leave the Examination Hall during the initial 90 minutes after distribution of the question paper. 5. Do not take away the question paper/answer sheet out of the Examination Hall. 6. Do not write/scribble or otherwise spoil the furniture and the admit card placed at your desk. 7. Do not carry any text material, printed or written, bits of papers, envelope in which admit card was dispatched or any other material except the admit card, inside the examination hall. 8. Do not copy the questions and answers on the admit card. 6
Part - I Particulars of Applicant: 1. Name (Full Name in Block Letters) 2. Date of Birth 3. Place of Birth 4. Address for communication
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